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Key Points: Bovine-derived collagen matrix (BDCM) is a safe augmentation material in patients with empty nose syndrome. BDCM augmentation results in clinically and statistically significant improvement in nasal symptoms. Improvements in nasal symptoms with BDCM augmentation may be durable and can be seen up to 2 years postoperative., (© 2024 ARS‐AAOA, LLC.)

The united airway refers to the combined upper and lower airways and their interconnected pathophysiologic relationships. Inflammatory airway diseases (chronic rhinosinusitis, asthma, and so forth) have been linked to fungal species through type 2 immune responses. These type 2 immune responses involve the cytokines interleukin (IL)-4, IL-5, IL-13, and a myriad of other inflammatory processes that lead to a spectrum of diseases from allergic bronchopulmonary mycosis to chronic rhinosinusitis. Historically, these diseases have been managed primarily with corticosteroids but recent revelations in the molecular pathophysiology provide opportunities for more diverse treatment options for patients with uncontrolled disease., Competing Interests: Conflict of interest A.U. Luong serves as a consultant for Lyra Therapeutics (Watertown, MA, USA), Medtronic (Dublin, IE), NeuroENT (Galway, IE), Sanofi (Paris, France), and Stryker (Kalamazoo, MI, USA). A.U. Luong serves on the scientific advisory board for ENTvantage Dx (Austin, TX, USA), Maxwell Biosciences (Austin, TX), and SoundHealth (San Francisco, CA, USA). D.B. Corry serves as a consultant for Maxwell Biosciences (Austin, TX) and owns intellectual property through Fannin Innovation Studio and Baylor College of Medicine., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak., Methods: A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test., Results: Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59-0.93, p  < .001)., Conclusion: The prevalence of DVS narrowing in patients with sCSF leaks is substantial and likely greater than the general population. Moreover, there appears to be narrowing in most patients with sCSF leak. Preoperative radiological evaluation of the DVS using MR venography may be useful in patients with sCSF leaks as DVS stenosis may be an underdiagnosed etiology. Further study is needed to evaluate this., Level of Evidence: IV., Competing Interests: William C. Yao serves as a consultant for Aerin Medical and on the speaker's bureau for Optinose Inc. Martin J. Citardi: Consultant: Acclarent, Intersect/Medtronic, LynxMD, MicroGenDx, Polyganics, Povinez. Amber U. Luong: Consultant: Acclarent, Lyra Therapeutics, Maxwell Bioscience, Stryker ENT, Medtronic, ENTvantage and Sanofi; Advisory boards: AstraZeneca and GlaxoSmithKline Grant support: Sanofi; Speaker honorarium: GSK and Aerin Medical. Karim W. Asi, Brian H. Cameron, Elliot R. Friedman, and Jeffrey P. Radabaugh: No financial disclosures., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years., Objective: To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options., Methods: Review article., Results: Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease., Conclusion: AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.

Introduction: The aim of this study was to evaluate the outcomes of radical cystectomy with an enhanced recovery after surgery (ERAS) protocol in patients with a history of chronic preoperative narcotic use compared to narcotic-naive patients., Methods: We identified 553 patients who underwent open radical cystectomy with ERAS. Preoperative narcotic use was identified in 34 patients who were then matched to 68 narcotic-naive patients. Postoperative outcomes, opioid use, and visual analog scale (VAS) pain scores were analyzed and compared. All routes of opioid use were recorded and converted to a morphine equivalent dose (MED)., Results: Patients with preoperative narcotic use reported higher median VAS pain scores per day (postoperative day [POD1]: 5.2 vs. 3.9, p=0.003; POD2: 5.1 vs. 3.6, p<0.001; POD3: 4.6 vs. 3.8, p=0.004) and used significantly more opioids (median MED) per day (POD1: 13.2 vs. 10.0, p=0.02; POD2: 11.3 vs. 6.4, p=0.003; POD3: 10.2 vs. 5.0, p=0.005) following surgery. Preoperative narcotic users were noted to have a significantly higher incidence of 90-day re-admissions (41.2% vs. 20.6%, p=0.03). There was no difference in median hospital stay (4 vs. 4 days, p=0.6), 30-or 90-day complications (64.7% vs. 60.3%, p=0.8 and 82.4% vs. 75.0%, p=0.4, respectively) or gastrointestinal complications (29.4% vs. 26.5%, p=0.8), including postoperative ileus (11.8% vs. 20.6%, p=0.2)., Conclusions: Patients with preoperative narcotic exposure report higher pain scores and require more opioid use following radical cystectomy with ERAS and are more likely to be re-admitted within 90 days. However, there was no observed difference in hospital stay or complications.

Objectives: Vocal fold (VF) stiffness and geometry are determinant variables in voice production. Type 1 medialization thyroplasty (MT), the primary surgical treatment for glottic insufficiency, changes both of these variables. Understanding the cause and effect relationship between these variables and acoustic output might improve voice outcomes after MT. In this study, the effects of thyroplasty implants with variable stiffness on glottal shape and acoustics were investigated., Methods: In an ex vivo human larynx phonation model, bilateral MT with implants of four stiffness levels (1386, 21.6, 9.3, and 5.5 kPa) were performed. Resulting acoustics and aerodynamics were measured across multiple airflow levels. A vertical partial hemilaryngectomy was performed and stereoscopic images of the VF medial surface taken to reconstruct its three-dimensional (3D) surface contour. The results were compared across implants., Results: The effects of implant stiffness on acoustics varied by airflow. Softer implants resulted in improved acoustics, as measured by cepstral peak prominence (CPP), at lower airflow levels compared to stiffer implants but this relationship reversed at high airflow levels. Stiffer implants generally required less airflow to generate a given subglottal pressure. Stiffer implants resulted in greater medialized surface area and maximal medialization, but all implants had similar effects on overall VF medial surface contour., Conclusion: Softer implants result in less medialization but better acoustics at low airflow rates. Stiffer implants provide better acoustics and more stable pressure-flow relationships at higher airflow rates. This highlights a potential role for patient-specific customized thyroplasty implants of various stiffness levels., Level of Evidence: NA., Competing Interests: The authors declare no potential conflict of interest., (© 2019 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals, Inc. on behalf of The Triological Society.)

Rhabdomyomas are benign tumors composed of mesenchymal tissue and having a histologic appearance similar to skeletal muscle. Extracardiac rhabdomyomas are rare, and the majority of the adult subtype occur in the head and neck (H&N) region. Diagnosis can be challenging due to fine-needle aspiration (FNA) and core needle biopsy being suspicious for sampling error from surrounding muscle or concerning for rhabdomyosarcoma. We present a case of a slowly enlarging left neck mass in the strap musculature of a 45-year-old Hispanic male. Multiple FNA and core biopsies failed to establish a diagnosis, and excisional biopsy was pursued revealing a hypertrophied left inferior belly of the omohyoid muscle. Histological analysis was diagnostic of an adult-type extracardiac rhabdomyoma, with complete surgical excision being the gold standard treatment for these tumors. The patient had an uneventful recovery. Skeletal muscle tumors of the H&N are uncommon, and benign extracardiac rhabdomyoma must be considered in the differential diagnosis to prevent unnecessarily aggressive intervention and appropriate patient counseling before and after surgery., Competing Interests: The authors declare that they have no conflicts of interest.

Purpose: The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques., Methods: We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications., Results: We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004)., Conclusion: This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper., Levels of Evidence: Level III-Treatment study, Retrospective comparative study., (Copyright © 2018. Published by Elsevier Inc.)

Background: The Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA., Methods: Gastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices., Results: Of gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20-50cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation., Conclusion: In Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes., Level of Evidence: Survey study. Level IV evidence., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Eyal and Hurst proposed that locally relevant medical education can offset the prevalence of physician "brain drain" in resource-poor regions of the world, and presented a framework of the ethical and pragmatic benefits and concerns posed by these initiatives. The present study explored the framework's utility through a case study of the University of Guyana Diploma in Surgery (UGDS) program., Methods: The framework's utility was evaluated using a case study design that included review and analysis of documents and semi-structured interviews with graduates, trainees, faculty members, and policy makers associated with the UGDS program. Data were analyzed from constructivist and interpretivist perspectives, and compared against the benefits and concerns described by Eyal and Hurst., Results: The framework is a useful template for capturing the breadth of experience of locally relevant training in the Guyanese setting. However, the results suggest that delineating the framework factors as either beneficial or concerning may constrict its applicability. The case study design also provided specific insights about the UGDS program, which indicate that the Program has promoted the retention of graduates and a sustainable culture of postgraduate medical education in Guyana., Conclusion: It is suggested that the framework be modified so as to represent the benefits and concerns of locally relevant training along a continuum of advantage. These approaches may help us understand retention within a resource-poor country, but also within particularly remote areas and public health care systems generally., Competing Interests: Conflicts of Interest: Co-author MR is the Director of the UGDS Program. Co-author BHC was formerly involved in the UGDS Program as a visiting CAGS surgeon. Neither MR nor BHC participated in the collection, analysis, or interpretation of data. The authors declare that they have no other competing interests.

Background: Burden of disease (BoD) as measured by Disability-Adjusted Life Years (DALYs) is one of the criteria for priority-setting in health care resource allocation. DALYs incorporate disability weights (DWs), which are currently expert-derived estimates or non-existent for most pediatric surgical conditions. The objective of this study is to establish DWs for a subset of key pediatric congenital anomalies using a range of health valuation metrics with caregivers in both high- and low-resource settings., Method: We described 15 health states to health professionals (physicians, nurses, social workers, and therapists) and community caregivers in Kenya and Canada. The health states summaries were expert- and community-derived, consisting of a narrated description of the disease and a functional profile described in EQ-5D-5 L style. DWs for each health state were elicited using four health valuation exercises (preference ranking, visual analogue scale (VAS), paired comparison (PC), and time trade-off (TTO)). The PC data were anchored internally to the TTO and externally to existing data to yield DWs for each health state on a scale from 0 (health) to 1 (dead). Any differences in DWs between the two countries were analyzed., Results: In total, 154 participants, matched by profession, were recruited from Kijabe, Kenya (n = 78) and Hamilton, Canada (n = 76). Overall calculated DWs for 15 health states ranged from 0.13 to 0.77, with little difference between countries (intra-class coefficient 0.97). However, DWs generated in Kenya for severe hypospadias and undescended testes were higher than Canadian-derived DWs (p = 0.04 and p < 0.003, respectively)., Conclusions: We have derived country-specific DWs for pediatric congenital anomalies using several low-cost methods and inter-professional and community caregivers. The TTO-anchored PC method appears best suited for future use. The majority of DWs do not appear to differ significantly between the two cultural contexts and could be used to inform further work of estimating the burden of global pediatric surgical disease. Care should be taken in comparing the DWs obtained in the current study to the existent list of DWs because methodological differences may impact on their compatibility.

Background: Pediatric surgical practice is different in low- and middle-income countries as compared to North America. While resources are limited, the impact of pediatric surgical procedures is significant. The objective of this study was to calculate and compare disability-adjusted life years (DALYs) averted in a Kenyan and Canadian surgical unit for a subset of pediatric congenital anomalies., Methods: Medical records of children having undergone surgical procedures for 13 congenital conditions in both surgical units were collected over 12 months. DALYs for each condition were calculated using previously obtained disability weights derived in each country. Age-adjusted life expectancy rates from the WHO were used to determine years of life lost. Risk of permanent disability without surgery and probability of successful treatment values were obtained from the literature and included in the DALY calculation., Results: The conditions accounting for the largest total number of averted DALYs in Kenya were hydrocephalus (60.8%) and spina bifida (18.1%), whereas in Canada they were hydrocephalus (24.2%) and undescended testes (19.2%). A total of 23,169 DALYs were averted through 1042 surgical procedures (22.2 DALYs per procedure) during the study period in Kenya, compared to 5497 DALYs through 373 procedures (14.7 DALYs per procedure) in Canada., Conclusions: Using recent developments in burden of disease measurement, the results point to the significant impact of pediatric surgical centers in addressing the global burden of congenital surgical disease. The study carries significant implications for resource allocation and training.

Background: Disability-adjusted life years (DALYs) have become the standard metric for estimating burden of disease (BoD), but have not yet been applied to delayed access to surgical procedures. This study estimates the DALYs accrued from delayed access to surgical care in two pediatric surgical units in Kenya and Canada., Methods: Records of operations for 13 congenital health states in a Kenyan and a Canadian hospital were prospectively collected for 2012. DALYs caused by delayed presentation were estimated using disability weights and ideal and actual age at surgery., Results: 1208 first-time procedures in general surgery, neurosurgery, plastic surgery, and urology were included. Delays were longest in general surgery and longer in Kenya than in Canada in all specialties. The longest delays in Kenya were for orchidopexy (72 months) and anorectoplasty (PSARP) (74 months), and in Canada for orchidopexy (40 months). Corresponding total delayed BoD was highest in general surgery and neurosurgery and higher again in Kenya than in Canada (484 cf. 84 DALYs)., Conclusions: Estimating BoD resulting from delayed surgery is feasible and reflects both late presentation and limited access to care. Further exploration of these factors can make delayed DALYs a useful measure of health care coverage and waitlist prioritization., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: International medical electives (IMEs) are unique learning opportunities; however, trainees can risk patient safety. Returning medical students often express concern about doing procedures beyond their level of training. The Canadian Federation of Medical Students has developed guidelines for pre-departure training (PDT), which do not address procedural skills. The purpose of this research is to determine which procedural skills to include in future PDT., Methods: Twenty-six medical students who returned from IMEs completed surveys to assess PDT. Using a Likert scale, we compared procedures performed by students before departing on IME to those performed while abroad. We used a similar scale to assess which procedures students feel ought to be included in future PDT., Results: There was no significant increase in number of procedures performed while on IME. Skills deemed most important to include in future PDT were intravenous line insertion, suturing of lacerations, surgical assisting and post-operative wound care., Conclusions: Pre-departure training is new and lacks instruction in procedural skills. Over half the students rated several procedural skills such as IV line insertion, suturing, assisting in surgery, post operative wound management and foley catheterization as important assets for future PDT.

The pioneering surgical training partnership between the Canadian Association of General Surgeons (CAGS) and the University of Guyana has successfully graduated 14 surgeons since 2006. The association has recruited 29 surgeons who have made 75 teaching visits to Guyana, and CAGS involvement has been critical to providing local credibility to the program, organizing the curriculum structure and developing rigorous examinations. The program is now locally sustained, with graduates leading a number of clinical hospital programs. The initial diploma qualification is being reassessed, as other specialties have introduced postgraduate Master of Medicine degree programs. Many graduates are pursuing additional training opportunities overseas, and almost all of those remaining in Guyana have returned to the tertiary centre from the regional hospitals. The program has succeeded in training surgeons and raising the standards of surgical care in Guyana, but broader health system efforts are necessary to retain surgeons in outlying regional hospitals.

Background: This survey compared surgical management of Hirschsprung's disease (HD) and anorectal malformations (ARM) in high and low resource settings., Materials and Methods: An online survey was sent to 208 members of the Canadian Association of Paediatric Surgeons (CAPS) and the Association of Paediatric Surgeons of Nigeria (APSON)., Results: The response rate was 76.8% with 127 complete surveys (APSON 34, CAPS 97). Only 29.5% of APSON surgeons had frozen section available for diagnosis of HD. They were more likely to choose full thickness rectal biopsy (APSON 70.6% vs. CAPS 9.4%, P < 0.05) and do an initial colostomy for HD (APSON 23.5% vs. CAPS 0%, P < 0.05). Experience with trans-anal pull-through for HD was similar in both groups (APSON 76.5%, CAPS 66.7%). CAPS members practising in the United States were more likely to perform a one-stage pull-through for HD during the initial hospitalization (USA 65.4% vs. Canada 28.3%, P < 0.05). The frequency of colostomy in females with vestibular fistula varied widely independent of geography. APSON surgeons were less likely to have enterostomal therapists and patient education resources., Conclusions: Local resources which vary by geographic location affect the management of HD and ARM including colostomy. Collaboration between CAPS and APSON members could address resource and educational needs to improve patient care.

Purpose: Patent Ductus Arteriosus (PDA) ligation in premature infants is an urgent procedure performed by some but not all pediatric surgeons. Proficiency in PDA ligation is not a requirement of Canadian pediatric surgery training. Our purpose was to determine the outcomes of neonatal PDA ligation done by pediatric surgeons., Methods: We performed a retrospective review of premature infants who underwent PDA ligation by pediatric surgeons in 3 Canadian centers from 2005 to 2009. Outcomes were compared to published controls., Results: The review identified 98 patients with a mean corrected GA and weight at repair of 29 weeks and 1122 g, respectively. There were no intraoperative deaths. The 30-day and inhospital mortality rates were 1% and 5%. Mortality and morbidity were comparable to the published outcomes., Conclusions: This study documents that a significant number of preterm infant PDA ligations are safely done by pediatric surgeons. To meet the Canadian needs for this service by pediatric surgeons, proficiency in PDA ligation should be considered important in pediatric surgery training programs., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background/purpose: Preterm infants needing patent ductus arteriosus (PDA) ligation are transferred to a pediatric cardiac center (CC) unless the operation can be done locally by a pediatric surgeon at a non-cardiac center (NCC). We compared infant outcomes after PDA ligation at CC and NCC., Methods: We analyzed 990 preterm infants who had PDA ligation between 2005 and 2009 using the Canadian Neonatal Network database. In-hospital mortality and major morbidities were compared between CC (n=18) and NCC (n=9)., Results: SNAP-II-adjusted mortality rates were similar (CC=8.7% vs NCC=10.7%, P=.32). Significant cranial ultrasound abnormalities (CC=24.1% vs NCC=32.1%, P<.01) and culture-proven sepsis (CC=39.7% vs NCC=54.8%, P<.01) were more frequent in infants treated at NCC. Infants transferred to CC had higher rates of cranial ultrasound abnormalities (transferred 31.6% vs non-transferred 20.4%, P<.01). NSAIDs prior to PDA ligation were used more often at NCC (CC 36.6% vs NCC 75.6%, P<.001)., Conclusions: Mortality rates after PDA ligation were similar at CC and NCC, but cranial ultrasound abnormalities and sepsis rates were higher at NCC. Higher morbidity may be associated with different PDA management strategies, including NSAID use or infant transfer. Further studies are needed to investigate the reasons for these differences in morbidity., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Professionalism is an important part of the hidden curriculum that is gaining attention in surgical education. McMaster University, Hamilton, Ontario, Canada, has introduced a small group discussion model using critical incident reports (CIRs) to elicit students' reflections on ethical, communication, and professionalism challenges during surgical clerkship. We described the themes identified by surgical clerks in their CIRs., Methods: Using thematic analysis, 4 investigators coded 64 CIRs iteratively until conceptual saturation. Rigor and validity were ensured throughout the process. Data were further explored to compare the CIRs of junior and senior clerks., Results: Twenty-seven themes and 4 relationship domains emerged: the clerk's relationship to patients, the health care team, the health care system, and self. Challenges with communication, the consent process, and breaking bad news were most commonly cited. Theme frequencies differed between junior and senior clerks., Conclusions: Small group discussions of critical incident reports allow surgical clerks to reflect on their developing professional relationships. The themes that have been identified can be used to guide professionalism education and uncover the hidden curriculum., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: We evaluated the retention of trauma knowledge and skills after an interprofessional Trauma Team Training (TTT) course in Guyana and explored the course impact on participants., Methods: A mixed-methods design evaluated knowledge using a multiple-choice quiz test, skills and trauma moulage simulation with checklists, and course impact with qualitative interviews. Participants were evaluated at 3 time points; before, after, and 4 months after TTT., Results: Forty-seven course participants included 20 physicians, 17 nurses, and 10 paramedical providers. All participants had improved multiple-choice quiz test scores after the course and retained knowledge after 4 months, with nonphysicians showing the most improved scores. Trauma skill and moulage scores declined slightly after 4 months, with the greatest decline observed in complex skills. Qualitatively, course participants self-reported impact of the TTT course included improved empowerment, knowledge, teamwork, and patient care., Conclusions: Interprofessional team-based training led to the retention of trauma knowledge and skills as well as the empowerment of nonphysicians. The decline in performance of some trauma skills indicates the need for a regular trauma update course., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: The Near Needle Holder (NNH) (Near Manufacturing, Camrose, Alberta, Canada) is a reusable tool to introduce a standard hollow needle for pediatric intraosseous (IO) infusion. We compared the NNH to the Cook Dieckmann (Cook Critical Care, Bloomington, IN) manual IO needle in a simulation setting., Methods: Study subjects were 32 physicians, nurses, and medical students participating in a trauma course in Guyana. After watching a training video and practicing under supervision, subjects were observed inserting each device into a pediatric leg model using a randomized crossover design. Outcome measures were time to successful insertion, technical complications, ease of use, and safety of each device., Results: The mean time for IO insertion (32 ± 13 seconds) was similar for both devices (P = .92). Subjects rated the NNH device equivalent in ease of use to the Cook IO needle but slightly lower in perceived safety to the user., Conclusions: After training, all subjects successfully inserted the NNH IO device in a simulation environment, and most rated it as easy to use and safe. The NNH is a significant advance because IO needles are often not available in emergency departments in developing countries. Further studies are needed to evaluate clinical effectiveness of the NNH., (Copyright © 2012 Elsevier Inc. All rights reserved.)

An accessory spleen is present in about 10-30% of the population and, usually, does not cause symptoms. We present a case report of an unusual presentation of accessory spleen infarction, with a literature review. A 12-year old male presented with acute left-upper quadrant pain that slowly resolved. An ultrasound and computed tomography scan showed a 3.5 x 2.5 x 2 cm solid mass abutting and displacing the splenic flexure of the colon, with surrounding inflammatory changes. This was interpreted as a colonic duplication cyst, and the boy was treated with antibiotics and underwent elective laparoscopic exploration. It was removed laparoscopically without complication and, on pathologic examination, proved to be consistent with an infarcted accessory spleen. Less than two dozen similar cases of accessory spleen infarction have been reported in the literature, most presenting with acute abdominal pain. Preoperative diagnoses included appendicitis, ovarian torsion, neoplasm, and, in our case, colonic duplication. The natural course of infarcted accessory spleen would be to atrophy, but, even with advanced imaging techniques, it may be impossible to diagnose infarcted accessory spleen with enough confidence to avoid surgery.

Background: Like many developing countries, Guyana has a severe shortage of surgeons. Rather than rely on overseas training, Guyana developed its own Diploma in Surgery and asked for assistance from the Canadian Association of General Surgeons (CAGS). This paper reviews the initial results of Guyana's first postgraduate training program., Methods: We assisted with program prerequisites, including needs assessment, proposed curriculum, University of Guyana and Ministry of Health approval, external partnership and funding. We determined the outputs and outcomes of the program after 2 years, and we evaluated the impact of the program through a quantitative/qualitative questionnaire administered to all program participants., Results: Five residents successfully completed the 2-year program and are working in regional hospitals. Another 9 residents are in the training program. Twenty-four modules or short courses have been facilitated, alternating Guyanese with visiting Canadian surgical faculty members coordinated through CAGS. A postgraduate structure, including an Institute for Health Sciences Education and Surgical Postgraduate Education Committee, has been developed at the Georgetown Public Hospital Corporation (GPHC). An examination structure similar to Canada's has been established. Hospital staff morale is greater, surgical care is more standardized and academic opportunities have been enhanced at GPHC. Four regional hospitals have welcomed the new graduates, and surgical services have already improved. Canadian surgeons have a greater understanding of and commitment to surgical development in low-income countries., Conclusion: Guyana has proven that, with visiting faculty assistance, it can mount its own postgraduate training suitable to national needs and will provide a career path to encourage its own doctors to remain and serve their country.

Background: Coil occlusion (CO) and video-assisted thoracoscopic surgery (VATS) have both emerged as minimal access therapies for patent ductus arteriosus (PDA). These techniques have not previously been statistically compared., Methods: Twenty-four consecutive children undergoing VATS for PDA were each retrospectively matched by PDA diameter and child weight to two children undergoing CO (total 48) during the same time period. The two modalities were compared with respect to outcome and cost. Statistical analysis was performed using a Student's t-test and Mantel-Haenszel relative risk. Cost analysis from an institutional perspective was used to compare resource consumption., Results: Mean PDA diameter was 3.6 +/- 1.2 mm in both groups. Mean age and weight for VATS and CO children were 2.7 and 2.9 yrs and 13.2 and 13.1 kg, respectively. Mean surgical times were 94 +/- 34 min for VATS and 50 +/- 23 min for CO (p < 0.0001). Mean length of stay was 1.6 +/- 0.2 days for VATS and 0.6 +/- 0.2 days for CO (Mantel-Haenszel RR (95% CI) = 0.15 [0.07, 0.29], p < 0.0001). Mean fluoroscopy time with CO was 13 +/- 7 min. No VATS or CO children required conversion to open surgical ligation. Two children in each arm (8% VATS, 4% CO) required indefinite antibiotic endarteritis prophylaxis for a persistent shunt. The cost per child was C$ 4282.80 (Canadian dollars) for VATS and C$ 3958.08 for CO., Conclusions: VATS is as efficacious for PDA closure as CO but requires longer surgical times and lengths of stay. Costs for each procedure are similar.

Background/purpose: Our preferred minimally invasive technique of Swenson's procedure has evolved from laparoscopic (LapSwen) to Swenson's transanal pullthrough (SWAP). We studied the incidence of postoperative Hirschsprung's enterocolitis (HEC) over the past decade., Methods and Materials: We retrospectively reviewed the charts of 52 children who had a primary Swenson's pullthrough procedure between 1995 and 2006. Two cohorts (25 LapSwen [1995-2000] and 27 SWAP [1998-2006]) were compared., Results: Median ages of diagnosis were 13 days for LapSwen and 4 days for SWAP. Median age at surgery was 4.1 months for LapSwen and 3.3 months for SWAP. Postoperative HEC occurred in 12% (16% LapSwen, 7.4% SWAP). The incidence of Down's syndrome and preoperative HEC did not differ between the 2 cohorts. Three children with HEC were Clostridium difficile-positive. Long-term function in the 36 children older than 4 years was excellent in 22%, good in 50%, fair in 11% and poor in 17%., Conclusion: Our incidence of postoperative HEC is low, and we have seen a trend toward fewer cases after the SWAP procedure. Early diagnosis, preoperative rectal irrigations, and routine postoperative anal dilatation may be contributing to the elimination of HEC as a significant risk after surgery for Hirschsprung's disease.

Background: Video-assisted thoracoscopic debridement (VATD) is a new method of managing pediatric empyema. The purpose of this retrospective study was to determine the relation between the timing of VATD and its success in avoiding the need for open decortication., Study Design: Twenty-one children aged 3 to 16 years (mean, 8 years) with symptomatic, loculated, parapneumonic empyema were treated with VATD at two tertiary pediatric centers between 1994 and 1997. The preoperative duration of symptoms, hospitalization, and previous need for thoracostomy drainage were compared between patients having VATD only and those who subsequently required a thoracotomy and decortication. Statistical analysis used the Wald chi-square test or Fisher's exact test with p < 0.05 considered significant., Results: Video-assisted thoracoscopic debridement was successful in 15 patients (group 1) and unsuccessful in six patients (group 2), who required a thoracotomy and decortication. Group 1 had a shorter mean duration of preoperative symptoms (13 versus 27 days; p=0.03), a shorter median duration of preoperative hospitalization (6 versus 18 days; p=0.04), and a lower incidence of previous thoracostomy drainage (4/15 versus 5/6; p=0.05)., Conclusions: The technique of VATD is most likely to be successful when used within one week of diagnosis of a loculated parapneumonic empyema. A prospective trial comparing VATD with intrapleural fibrinolytic agents for the initial treatment of pediatric empyema is needed.

Purpose: The Nissen fundoplication fails to control gastroesophageal reflux (GER) in up to 25% of children with neurological impairment or chronic lung disease. The uncut Collis modification lengthens the intraabdominal esophagus, improving the antireflux function without opening the stomach. This study reviews the results of the uncut Collis-Nissen fundoplication in a pediatric series., Methods: Seventy-nine children had an uncut Collis-Nissen fundoplication performed over a 5-year period. The median age was 1.4 years. Associated problems included neurological impairment (77%), chronic lung disease (38%), and esophageal atresia (3%). Surgery was undertaken only in children with objective documentation of pathological GER, who had GER complications unresponsive to medical treatment. The usual complications that led to surgery were pulmonary (73%), esophagitis (67%), or failure to thrive (35%). Liquid gastric emptying was assessed routinely preoperatively, and was delayed in 42% patients who then had concomitant pyloroplasty., Results: GER was controlled in 97% of patients after a median follow-up of 1.8 years. All children with recurrent symptoms were restudied, and only two children had documented recurrent GER. One of these required a repeat fundoplication. Thirty-three percent were on promotility medication for feeding difficulties, gagging, or retching. There were postoperative complications in 26% (minor 23%, major 3%) and one postoperative mortality. Eleven late deaths were unrelated to surgery or GER., Conclusion: The uncut Collis-Nissen fundoplication provides excellent control of GER in children and is associated with acceptable morbidity and low mortality. It should be particularly considered in children with neurological impairment or chronic lung disease.

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.

Severe caustic injury with stricture may require esophageal reconstruction. The available methods of esophageal substitution do not satisfactorily replace the peristaltic and antireflux properties of the native esophagus. The authors report the results of two children treated with colon patch esophagoplasty and preservation of the injured esophagus. Both were 2 years of age when they accidently swallowed lye. Long esophageal strictures developed, which were resistant to repeated dilatation. Eleven and 13 months after the injury, the patients underwent colon patch esophagoplasty. A segment of the left colon was tailored to the length and shape of the opened stricture and was anastomosed side-to-side to the esophagotomy. One child later had a short recurrent stricture and diverticulum, which required revision of the distal end of the anastomosis. Follow-up endoscopic examination has shown healing of the esophagus and resolution of the strictures; both children are eating normally 3 years after surgery, without symptoms of gastroesophageal reflux. Colon patch esophagoplasty is an alternative to esophageal replacement for long caustic esophageal strictures. Its advantage is preservation of the peristaltic and antireflux mechanisms of the conserved esophagus.

Neurologically impaired children frequently require a feeding gastrostomy. Few reports are available comparing the incidence of postoperative complications and symptomatic gastroesophageal reflux after endoscopic versus operative Stamm gastrostomy in this group of children. We undertook a retrospective study of 63 consecutive neurologically impaired children requiring a feeding gastrostomy, with an average of 23 months of follow-up. No child had symptomatic gastroesophageal reflux. Thirty children had a percutaneous endoscopic gastrostomy and 33 had a Stamm gastrostomy, depending on the preference of the surgeon. The two groups were comparable in age range, cause of neurologic impairment, and indication for gastrostomy. Minor complications occurred in 30%. All three major complications occurred after Stamm gastrostomy, including two postoperative deaths. Symptomatic gastroesophageal reflux developed in 60%. The incidence of fundoplication after gastrostomy was 10% in the percutaneous endoscopic gastrostomy group and 39% after Stamm gastrostomy (p < .025). Morbidity was lower after percutaneous endoscopic gastrostomy than after Stamm gastrostomy in this group of neurologically impaired children. Fundoplication for symptomatic gastroesophageal reflux was infrequent after percutaneous endoscopic gastrostomy and significantly more common after Stamm gastrostomy. Percutaneous endoscopic gastrostomy is recommended as the initial procedure in neurologically impaired children without symptomatic gastroesophageal reflux who require a feeding gastrostomy.

Neuroblastoma presenting as obstructive jaundice is very rare. The authors present two cases of neuroblastoma, one primary and one recurrent, manifesting as a malignant obstruction of the extrahepatic biliary system. Various methods of biliary decompression were considered in these children including transhepatic or retrograde biliary stenting and internal cholecystoenteric bypass. An attempt at percutaneous transhepatic stent placement failed in one case. In each patient, a simple insertion of a cholecystostomy tube proved effective. Immediately postoperatively, both patients had rapid resolution in symptoms and a decrease in bilirubin levels. Transient mild cholangitis in both children was successfully treated with antibiotics. Chemotherapy reduced the tumor size in each case, and the cholecystostomy tubes were removed within 3 weeks, after cholangiography showed patency of the distal common bile ducts. Temporary cholecystostomy tube drainage and systemic chemotherapy proved to be a safe, simple, and effective method for managing obstructive jaundice caused by neuroblastoma in these two cases.

Advanced laparoscopic biliary procedures can be undertaken in a pig model, but the small size of the normal common bile duct makes learning difficult. We have developed a prepared pig model of common bile duct ligation on which to practice advanced laparoscopic biliary surgery. The pig's distal common bile duct was occluded using several different methods via a minilaparotomy. Laparoscopic biliary procedures were undertaken 6-21 days later. The common bile duct became dilated to between 2 and 3 cm in diameter in all cases, and this was well tolerated by the animals. All advanced laparoscopic biliary procedures were possible, including choledochoscopy, exploration of the bile duct, and cholecystojejunostomy. Short-term common bile duct ligation is well tolerated in pigs and can be used to create a model for practicing advanced laparoscopic biliary procedures.

A 12-year-old girl with acute gastric volvulus associated with severe scoliosis and neurological impairment did well initially with nasogastric tube decompression. To prevent recurrence, anterior gastropexy was performed using percutaneous sutures through the abdominal wall and stomach with the gastroscope in place. Simultaneous laparoscopic guidance was used to ensure that the stomach was fixed in a nonrotated position. One year later, volvulus has not recurred. This method of gastropexy is indicated only in children with intermittent gastric volvulus who do not have an underlying abnormality such as diaphragmatic hernia.

Hydatid lung disease due to Echinococcus granulosus in the Canadian northwest and Alaska is often asymptomatic and usually benign. We reviewed the course and outcome of three children with giant hydatid lung cyst seen over a 2-year period. All were North American Indian children aged 9 to 12 years who presented with cough, fever, and chest pain. One had a rash. There was a history of exposure to domestic dogs who had been fed moose entrails in each case. Chest x-rays showed solitary lung cysts with air-fluid levels, from 6 cm to 12 cm in diameter. Aspiration of each cyst demonstrated Echinococcus hooklets and protoscolices. Serology was unhelpful, being negative in two cases. Transient pneumonitis and pneumothorax were seen as complications of needle aspiration. Two cysts gradually resolved over the following 6 months. One child returned after 9 months with a lung abscess due to superimposed infection of the cyst remnant with Haemophilus influenzae, and eventually required lobectomy. The existence of an endemic benign variant of E granulosus in Canada is not widely known, and it is important to distinguish it from the more aggressive pastoral form of the disease seen in immigrants from sheep-rearing countries. The native Canadian disease usually resolves spontaneously, does not cause anaphylaxis, and does not implant daughter cysts if spilled. Surgical treatment should be avoided except for complications such as secondary bacterial infection.

In summary, we have presented a large Canadian kindred exhibiting hereditary large bowel cancer, without polyposis coli, transmitted in an autosomal dominant fashion (Hereditary Site-Specific Colon Cancer). This series serves to emphasize the heritable nature of this and other malignant conditions and the importance of so fundamental a concept as the taking of a complete family history in the identification and management of these conditions. Looking to the future, the reduction of morbidity and mortality from Hereditary Site-Specific Colon Cancer lies in the education of the family and genetic counselling, both commencing in the mid teens the education of physicians and surgeons in the very considerable risk of malignancy in this condition the surveillance of asymptomatic family members including such measures as stool testing for occult blood six monthly augmented by air contrast barium enema and/or colonoscopy at two yearly intervals, commencing at age 25 the creation of national and international registries the identification of reliable biomarkers. We are indeed fortunate to live in a age when technology holds promise for the identification of the oncogenes operative in this and other heritable malignancies. This is the subject of ongoing collaboration between us and our molecular biology colleagues at Memorial University in St. John's and exemplifies, I believe, the very best in the cooperative spirit which may exist between a community hospital and a larger teaching centre.

A 2-year-old Fijian boy presented with a week's history of fever and dysuria. On ultrasound scan of the abdomen, he was found to have an appendicular mass. The role of ultrasound in the diagnosis is emphasized as well as the need for consideration of appendicitis in any young child with abdominal pain.

A large kindred with colorectal cancer unaccompanied by polyposis coli and characterized by autosomal dominant inheritance has been identified in eastern Canada. Ten family members from three successive generations have presented 17 documented colorectal cancers. The clinical features of the kindred are characteristic of hereditary site-specific colon cancer (HSSCC) (Lynch syndrome I): absence of multiple polyposis, autosomal dominant inheritance, onset of colorectal cancer at an early age and a high incidence of synchronous and metachronous colorectal cancers. A unique feature of this family is the high incidence of sporadic adenomatous polyps in affected members and their relatives. Patients with HSSCC have been managed by means of segmental colectomy followed by annual colonoscopic surveillance. All five patients with localized (Dukes' stage A or B) cancer at initial diagnosis were alive and free of disease after 2 to 12 years of follow-up, although three had required further colonic resection for metachronous carcinomas. Five young family members without cancer have had sporadic adenomatous polyps removed and are being followed with annual colonoscopy. It is not known whether polypectomy will alter the subsequent incidence of colon cancer. Subtotal colectomy is recommended for patients with HSSCC because of the high incidence of multiple lesions. An aggressive screening protocol, including colonoscopy, is recommended for all adult first- and second-degree relatives of patients with HSSCC. Identification of a biomarker, which is currently being sought in this kindred, would help identify those at greatest risk of development of cancer and allow earlier intervention.